=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205070091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY R SYDDALL PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2009
-----------------------------------------------------
Last Update Date | 12/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 W 2100 S
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84119-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-213-9700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10479 S SAGE VISTA WAY
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-3955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-243-6178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 7270173-1206
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------